Understanding the NHS: How to Get the Most from Our National Health Service

By Andy Stein, Yakup Kilic and James Korolewicz

The NHS is more than a good idea. It is beautiful. And it is you. The importance of the NHS – and the public’s affection for it – cannot be overstated, as seen through the COVID-19 pandemic. The author and his family of medics have lived and breathed the NHS, from before 1948, its birth and its history to date. But this book is for people who do not come from this medical background and do not have this life experience. Thus there are three target audiences. Firstly, it can contribute to A level study of the NHS, and career advice for 6th form students who are applying to university for a degree in healthcare. Secondly, it will educate health and social care professionals in training and in their early years. So they can start with the knowledge that the author had when he went to university in 1979. Thirdly, the book is for everyone else, who want to know how it all fits together, and in this way, improve their healthcare, and that of their family.

• Language: English
• Publisher: Open Road Integrated Media
• Release date: Jul 28, 2022
• ISBN: 9781399007979

Book preview

Introduction

People don’t believe in ideas, they believe in people who believe in ideas

Ze’ev Mankowitz

The NHS is more than a good idea. It is beautiful. And it is you. If you didn’t believe in it, you probably would not be reading this book. And what an idea it is, one the greatest in modern compassionate society, i.e. to make healthcare equal. I hope this book enables you to do two things with that idea. One. Believe in it every day, and pass on that belief. Two. Work hard and lead the NHS throughout your career.

The idea, its beauty, and this book, have been in my head for most of my life. Why write it? I wanted to write down what I have learnt (and seen) over the last 60 years in the NHS. So how did it all start for me?

Well. I went to Nottingham Medical School in 1979 (it was newish, nine years old and felt ‘fresh’). 1979 seems like anther age now. Industrial unrest helped Mrs Thatcher come to power. Devolution. Liverpool FC (my team) won the old 1st Division. Douglas Adams published his first masterpiece (as I saw it at the age of 17 years old), ‘The Hitchhiker’s Guide to the Galaxy’. In 1979, the NHS was still quite ‘young’ (31 years old). But my experience goes back to early childhood, in the early 60s – as I come from a medical family. And being the 7th Dr Stein (so far), I know, is not very original.

But not everyone has had my family’s life story. My family’s medical story starts post WW1. My maternal grandfather trained at the old Charing Cross Medical School (now part of Imperial College, London) and was a GP and Public Health Physician in Cheltenham in the 1920-30s. He met his wife, a nurse, as a junior doctor at Charing Cross Hospital. He was in the Army, went over in the British Expeditionary Force in WW1, was captured at Dunkirk and became a prisoner-of-war (ending up in Colditz) for 5 years - then a GP again. My mother trained at Newnham (Cambridge) and King’s College London, which is now part of ‘GKT’ (Guys, Kings and Thomas’). She was an Obstetrician and Gynaecologist, then a GP, then a Public Health Physician, finishing her career as the Regional Medical Officer for SE Thames. Thus as a family, we have always had an interest in the ‘bigger picture’ (i.e. public health), not just the patient in front of us.

My father trained at Trinity College, Dublin, the first in his family to go to university. His father was a rag and bone man. My father was a GP, specialising in paediatrics, and a doctor in the RAF in WW2 - North Africa, Italy, the whole shebang. Post-war, as a GP before 1948, he established a practice in a poor area, in a poor town in Kent. He had a ‘panel’ (list) of patients but only working males were allowed on the list and received government-funded healthcare. Some were too poor to get on the list, and would pay him in kind, a farmer with eggs etc. Women and children were not a priority for the pre-NHS health system.

My parents worked together. Each would have alternate Thursday afternoons off and alternate weekends. Our home was the surgery. Opening my Dad’s medical bag was never a good idea for a young child, usually leading to a question to him, Where does this metal thing go? Does it hurt?. Contraceptive devices ended up in the cutlery drawer. You get the idea. So, we, as a family, lived and breathed the NHS, from before 1948, its birth and its history to date. I still do. That is a privilege.

But this book is for people who do not come from this background and do not have this life experience. They do not know how it works, and would like to know. They start off thinking it is one thing. Wrong. It is actually 7-8 silos that do not talk to each other. Each has different email and admin systems; different lines of finance; and different traditions, ambitions and ideas. They are also sometimes are in competition with each other. This makes people confused, frustrated and even angry, with the system. They do not know why it is so, and how to navigate themselves through the NHS.

Thus I have three target audiences. Firstly, I would like to educate health and social care students, and junior professionals in their early years; so they can start with my knowledge when I went to university in 1979. Secondly, it can contribute to career advice for 6th form students who are applying to university for a degree in health or social care. Thirdly, the book is for everyone else, who want to know how it all fits together; and in this way, improve their healthcare, and that of their family.

Thus, this book is written both for future and new health and social care professionals, and the interested general public. Its aim is to pass on the great idea, teach you how the NHS works, and enable you to provide better care for your patients, and receive better care (for you and your family).

Chapter 1

History of NHS: Beginning and Consolidation

This chapter describes the circumstances leading up to the establishment of the NHS, and its first 42 years and is an historical timeline with some medical context.

Cartoon 1.1: NHS Announced.

Introduction

Let’s look at the word ‘NHS’.

National: While the NHS covers all four constituent nations of the United Kingdom, it has taken different routes in each country. England and Wales have usually dovetailed, while Scotland and Northern Ireland exercise more autonomy.

Health: When the NHS was founded in 1948, male life expectancy at birth was 66 years. In 2020, it was 81. With this demographic transition comes an increased burden of chronic disease. Our ideas of health have similarly altered to include a more holistic account of health, supplementing physical fitness with mental, social, and spiritual wellbeing.

Service: What it means for the NHS to serve its public has changed over the course of its existence. Are the people sitting in the waiting room patients, clients, service users, or well-informed customers?

Pre-Twentieth Century Healthcare

In the 16th Century, the first Poor Law established almshouses to care for the poor and sick, with a system of ‘outdoor relief’; providing benefits in kind to support the poor at home.

During the first half of the 19th Century, almshouses, and outdoor relief were thought to encourage dependency. So the State abolished direct welfare payments and established workhouses, austere large institutions for the care of the needy. Towards the end of the century, annexes were added to house the sick, the first infirmaries, in some respects, the first hospitals. Care was rudimentary with Florence Nightingale, amongst others, commenting on the atrocious conditions.

As the anatomical and pathological basis of disease became better understood, healthcare was increasingly provided by other bodies. Local councils established both ‘Municipal Hospitals’ for infectious diseases (many of which became ‘District General Hospitals’), and institutions for people with mental or physical illnesses or intellectual disabilities.

Additionally, many ‘Voluntary Hospitals’ were established as charities where medical care was provided by visiting specialists who had lucrative private practice elsewhere. For economic reasons, such hospitals focused on people with acute problems not requiring long-term care. Some of these hospitals later became modern ‘teaching hospitals’ (see Chapter 6).

Primary and community care services evolved separately from the hospitals. Community care, including domiciliary, environmental and public health services, had always been the responsibility of the local authority. Regular epidemics, particularly of smallpox, typhus and cholera, drew attention to the need for sanitary and preventative measures. So from the mid-nineteenth century, local health boards had legal powers to protect water supplies, promote vaccination and enforce quarantines. However, it was not until the beginning of the twentieth century, that a primary care doctor service (i.e. a ‘general practitioner’, GP) was funded through insurance schemes.

This is the early timeline of healthcare development:

1808. Mental Health. County Asylums Act 1808 established asylums for poor and criminally insane, mentally ill people; the first opening in Northampton in 1811.

1815. Apothecaries Act 1815 introduced compulsory apprenticeship and formal qualifications for apothecaries (later called general practitioners, GPs), under the license of the Society of Apothecaries.

1828. Mental Health. County Asylums Act 1828 required magistrates to send annual records of admissions, discharges, and deaths in asylums to the Home Office. It also imposed the requirement of a residential medical officer.

1832. British Medical Association launched under the name of the Provincial Medical and Surgical Association; with the objective of sharing medical knowledge.

1839. Public Health. The Poor Law Commission’s fifth annual report. The report concluded the prevalence of disease was linked to substandard living conditions in England’s industrial cities.

1841. UK Census. Estimated that a third of doctors in England were unqualified.

1845. Mental Health. Lunacy Act 1845 and County Asylums Act 1845. The Lunacy Acts changed the status of mentally ill people to patients.

1848. Public Health. Public Health Act 1848 and the General Board of Health established the General Board of Health and Local Boards, to advise on public health matters. The Act gave towns the right to appoint a Local Board of Health, led by a Medical Officer (now the Director of Public Health, DPH).

1853. Public Health. United Kingdom Vaccination Act 1853. Legislation made it compulsory for all children born after 1 August 1853 to be vaccinated against smallpox.

1854. Public Health. Improvements in Hospital Hygiene. Florence Nightingale returned from running military hospitals during the Crimean War, and instigated sanitary improvements in British hospitals, cementing the modern profession of nursing.

1858. Medical Act 1858. General Medical Council (GMC) was formed centralising the regulation of doctors in the UK.

1858. Public Health. Local Government Act 1858 abolished the General Board of Health. Its responsibilities were taken on by the Secretary of State for the Home Department, the Local Government Act Office, and the Privy Council.

1863. Mental Health. Establishment of first forensic mental health hospital in England, Broadmoor Criminal Lunatic Asylum.

1872 and 1875. Public Health. Further Public Health Acts enforced laws about slum clearance, provision of sewers and clean water.

1889-1902. Public Health. Arguably, discovering a third of those volunteering to fight in the Boer War (1899–1902) were rejected because of poor health, led the government to realise ‘something had to be done’ to improve the nation’s health.

1890. Mental Health. Lunacy Act placed an obligation on local authorities to maintain institutions for the mentally ill.

Twentieth Century (pre-1940)

1905. The Royal Commission on the Poor Law and the Unemployed. The ‘majority’ and ‘minority’ reports released in 1909 criticised the duplication of health services provided by voluntary and Poor Law institutions, but their recommendations differed.

1910. Origin of the phrase ‘NHS’. Dr Benjamin Moore was probably the first to use the words ‘NHS’ in The Dawn of the Health Age. He established the State Medical Service Association in 1912, replaced by the Socialist Medical Association in 1930.

1911. National Insurance Act 1911. Previously, systems of health insurance consisted of private schemes such as friendly societies or welfare societies. But in 1911, David Lloyd George (then Chancellor of the Exchequer) created a system whereby a small amount was deducted from weekly wages, supplemented by contributions from the employer.

Under this Act, all eligible working males could register with a GP. GPs who took part in this scheme were called ‘panel doctors’ and received an annual ‘capitation’ fee; a funding mechanism still used today. This was a very important act and in some ways, the real ‘birth’ of the NHS. For the first time, central government finance was used to provide medical care for the people.

1918. Pandemic. Spanish Flu (January 1918 - December 1920). Was caused by the transmission of an avian influenza virus to humans killing about 50 million people worldwide. It was followed by similar viral pandemics including Asian Flu (1957; 2 million deaths), Hong Kong Flu (1968; 1 million), HIV/AIDS (1981+, 33 million+), Swine Flu (2009; 300,000), Ebola (2013; 11,000) and COVID-19 (2020; over 5 million in November 2021).

1919. Ministry of Health. The First World War was a catalyst for social change with Lloyd George promising a land fit for heroes to live in. This included the creation of the Ministry of Health.

1919. Nurses Registration Act 1919. This established a regulator for nurses, the General Nursing Council for England and Wales.

1920. Dawson Report suggested the organisation of medicine was insufficient to bring the advances of medical knowledge within the reach of the people.

1924. Royal Commission on National Health Insurance. The Commission’s ‘majority report’, in 1926, found the system effective and recommended its extension to dependents. Its ‘minority report’ found the involvement of industrial insurance companies detrimental to the expansion of public health and recommended provision through public funding.

1929. Local Government Act allowed local authorities to run services over and above those authorised by the Poor Laws.

1930. Socialist Medical Association formed, and in his first Presidential address in May 1931, Somerville Hastings (a Labour politician and surgeon) outlined the principles for a new type of medical service: preventive, universal and without economic barriers.

1934. Labour Conference (Southport). The party ratified a motion on the creation of an NHS by Somerville Hastings.

1938. The British Medical Association (BMA) published a pamphlet: ‘A General Medical Service for the Nation’. It described how health insurance should be extended to the dependents of wage-earners.

The 1940s

1939. At the outbreak of war, central government took over voluntary and municipal hospitals establishing the Emergency Medical Service. Doctors and nurses were, for the first time, employed by a centralised state-run system. Oddly, healthcare often advances in war.

1942. An Inter-Departmental Committee led by Sir William Beveridge published the Beveridge Report calling for a comprehensive system of social insurance ‘from cradle to grave’. It proposed all working people should pay a weekly contribution to the State with benefits to be paid to the unemployed, the sick, the retired, and the widowed. This is one of the most important documents in the social history of the UK and might be considered the manifesto of the Welfare State.

1946 (July). NHS Act 1946 published.

1948. Creation of the NHS.

Following WWII, Britain’s first majority Labour government, led by Clement Attlee, formulated plans for a comprehensive Welfare State. A free at point-of-delivery NHS was the cornerstone of these plans.1

Picture 1.1: Aneurin Bevan, Minister of Health, on the first day of the National Health Service, 5 July 1948, at Park Hospital, Davyhulme, near Manchester.

The chief architect of the NHS was Labour Minister of Health, Aneurin Bevan. On 5 July, he launched the NHS at Park Hospital in Manchester (Trafford General Hospital).

The NHS in Scotland and Northern Ireland were legally distinct from England from the beginning, Wales, however, was managed from England and treated much like an English region for the first 20 years. This is what the ‘tripartite system’ of the new NHS looked like in 1948.

Hospitals

•State owned (nationalised) hospitals. 1.143 voluntary and 1,545 municipal hospitals became the responsibility of 14 Regional Hospital Boards in England and Wales.

•The 36 ‘Teaching Hospitals’ had different arrangements and were organised under Boards of Governors. Hospital consultants retained the right to conduct their private practice as well as gaining full-time salaried employment in the NHS. This is still the case.

•In 1948 hospitals were managed by a medical superintendent, a matron and a lay administrator (called the ‘secretary’) 2.

General practice

•The national network of general practitioners extended (and replaced) the ‘panel system’ and included the entire population. GPs were responsible for primary healthcare and received fees which were set and paid nationally. Each person would be registered to a specific GP. On 5 July 1948 (when the NHS officially ‘started’), 86% of all GPs joined it, and over the next six months the proportion rose to 96%.

Figure 1.1: Original structure of the NHS. After Rivett (ND).

Community and domiciliary health services

•Maternity and child welfare clinics, health visitors, midwives, health education, ambulance services, public and environmental health and health promotion (including vaccination) continued to be run by City or County councils (Local Authorities), which were also responsible for housing, roads and education.

The NHS’s original management structures in 1948 consisted of:

•14 Regional Health Boards (RHBs)

•36 boards of governors for teaching hospitals (BGs)

•388 hospital management committees (HMCs)

•138 executive councils (ECs)

•147 local health authorities (LHAs).

The NHS made an immediate impact on the health and imagination of the nation. In 1952, Aneurin Bevan said:

The essence of a satisfactory health service is that the rich and the poor are treated alike, that poverty is not a disability, and wealth is not advantaged.

The strands of the tripartite system had, and still have, different funding streams and were managed separately. This was possibly the biggest mistake in the NHS – made at its creation.

The Central Health Services Council (CHSC) was created by the 1946 NHS Act and was the advisory mechanism for the Ministry of Health. It had substantial representation from the professions as well as members from local government and hospital management.

There were also Standing Advisory Committees which remained in existence until 2005: the Standing Medical Advisory Committee (SMAC); Standing Nursing and Midwifery Advisory Committee (SNMAC), Standing Pharmaceutical services Advisory Committee (SPAC) and Standing Dentistry Advisory Committee (SDAC).

Even though the NHS ‘started’ in 1948, we hope you can see, it was really a development of previous organisations and Acts of Parliament. This gathered pace from the start of the Twentieth Century and the National Insurance Act of 1911 was vital. Its formation was beautiful (in our eyes)3.

1948. Health Services Act (Northern Ireland) 1948.

1949. The Nurses Act 1949 established a framework for the role of nursing within the NHS.

1949. The NHS (Amendment) Act 1949 safeguarded the independence of GPs. It also proposed prescription charges of not more than one shilling per prescription. However, due to intense opposition, the charges were not implemented until 1952.

The 1950s

After initial success in the eyes of the public, costs started to spiral. So various services were then taken out of the new NHS. Mass vaccination and intensive care started. First Clean Air and Mental Health Acts.

1950. Education. Medical Act 1950 introduced disciplinary boards and a compulsory year of training for doctors after their university qualification.

1950. Research. First UK Report Linking Smoking to Lung Cancer.

1952. Prescriptions, Dental charges (mainly dentures) and Spectacles. Originally ‘free’, charges for these items were now introduced. As of 2021 prescription charges remain in England, but were abolished in Wales, Northern Ireland and Scotland in 2007, 2010 and 2011.

1952. Royal College of General Practice established.

1952. Clinical. Birth of Intensive Care Concept.

1953. Research. Structure of Deoxyribonucleic Acid (DNA) described.

1955. Clinical. UK’s First Kidney Transplant.

1956. Public Health. The Clean Air Act was a response to worsening air pollution in urban areas of the UK; the 1952 Great Smog in London killing an estimated 12,000 people.

First Mass Vaccination Programme. Polio and diphtheria jabs were offered to under fifteens.

1959. Clinical. First General ICUs in UK.

1959. Mental Health Act recommended, where possible, treatment in the community - and mental and physical health should have equal status.

The 1960s

Oral contraception, and the Abortion Act, contribute to the changing roles of men and women in society.

1961. Public Health. Oral Contraceptive Pill. The contraceptive pill gave women birth control, though only available to married women until 1967.

1962. Birth of the Modern Hospital. A Hospital Plan for England and Wales was proposed by Health Minister, Enoch Powell, as a ten-year vision for hospital building. 14 Regional Health Boards (RHBs) oversaw planning and building of one new DGH per 125,000 of population. This led to 90 new hospitals, with 134 extensively remodelled.

All DGHs were to have Accident and Emergency and Outpatient Departments. Single-speciality hospitals went out of favour, except in London, where single organ hospitals (like the Moorfield Eye Hospital) still exist. Only people requiring specialised care, e.g. cardiac and neurosurgery, needed to travel to regional teaching hospitals, which were mostly in big cities.

1962. Medical Services Review Committee’s final report (Porritt Report) proposed a reform of the tripartite system, with the administration and co-ordination of medical and other services, under one Area Health Authority.

1964. Artificial Fluoridation of Water Supply.

1964. Clinical. First Coronary Care Unit (CCU) in UK (Edinburgh).

1967. Public Health. NHS Family Planning and Abortion Acts made abortion legal up to 28 weeks (24 weeks in 1990) if a woman’s mental or physical health was at risk. The Act did not cover Northern Ireland until 2020.

1967. Research. Whitehall Studies (large prospective cohort studies) commenced, investigating social determinants of health - specifically the cardiovascular disease prevalence and mortality rates among British civil servants.

1967. Salmon Committee’s Report (Senior Nursing Staff Structure) made recommendations for developing staff structure and embedding the profession in hospital management - heralding the